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#0821-RH1150-AC
Supplemental Questionnaire

Last Name
First Name

 

Submit responses to the following questions with your employment application to the San Joaquin County Human Resources Division. Please provide a detailed description of your work experience. These questions will be reviewed in evaluating your qualifications.
1.
Do you possess a Master’s Degree in nursing which meets the State of California Clinical Nurse Specialist requirements?
Yes No
 

If yes, please state the college or university in which you obtained your Master's in Nursing.
2.

Do you possess at least 2 years of full time experience as a registered nurse in an acute care facility's Neonatal Intensive Care Unit?
Yes No
 

If yes, describe the advanced nursing duties you performed in a Neonatal Intensive Care Unit. Include the following in your answer:

  • The name of the hospital facility.
  • Your position title.
  • Number of years in the department.
  • Number of staff you precepted in the department.
  • Number of staff you supervised or evaluated in the department.

 
3.
Please provide your Clinical Nurse Specialist Certification number as issued by the State of California:
4.

This position requires a license as a Registered Nurse issued by the State of California Board of Registered Nursing.  Provide your license number and expiration date.
5.
Do you possess a valid California Driver's License?
Yes No